Genetic lesions affecting ciliary structure and function give rise to a broad collection of genetically heterogeneous and clinically overlapping disorders, known collectively as the ciliopathies, which are characterized by both phenotypic overlap and variable penetrance and expressivity. In the retina, a modified cilium plays an integral role in protein transport across the photoreceptor and is critical for retinal architecture and function, as evidenced by the fact that progressive photoreceptor degeneration is a hallmark of numerous ciliopathies. Accumulating evidence suggests that genes mutated in some ciliopathies can contribute both causal and modifying alleles across the ciliopathy spectrum, giving rise to the idea that both cis and trans acting alleles can contribute to the mutational load of ciliopathy patients and offer the possibility that understanding the genetic architecture of ciliopathies might inform the mechanisms that underlie phenotypic variability in human genetic disorders. To explore this notion, we have previously conducted unbiased medical resequencing of genes known/expected to be important to ciliary biogenesis and function in a large, clinically diverse cohort of patients that span the spectrum of severity. In RPGRIP1L, a gene known to cause neonatal lethal Meckel-Gruber Syndrome (MKS) and moderately severe Joubert Syndrome (JBTS), we identified a highly-conserved A229T change which was present at intermediate population frequency, and was significantly enriched in patients with retinal degeneration. Using an interdisciplinary approach, we went on to show that the Thr229 allele is a non-neutral change that disrupts the direct interaction between RPGRIP1L and RPGR, the most frequent genetic cause of X-linked Retinitis Pigmentosa (XLRP). These data offer us the opportunity explore the genetic mechanism(s) of second-site modification in retinal phenotypes in ciliopathies, and to develop models that can be used to probe such phenomena further. We propose two aims. First, motivated by the opportunity to develop a robust model to study epistasis, we will model the A229T change by introducing it into a mouse model and subsequently crossing the Thr229 allele into lines with sensitized ciliary function to determine if this allele will either induce or exacerbate retinal phenotypes. Second, because our preliminary data suggest that RPGRIP1L might also contribute epistatic alleles to non-syndromic retinal degeneration, we will expand the mutational analysis of RPGRIP1L to an extended cohort of non-syndromic patients and matched controls. Using our previously established in vivo complementation strategy, we will then test the pathogenic potential of newly discovered alleles, and, empowered with functional data, we will determine the overall enrichment of RPGRIP1L alleles in retinal degeneration. The completion of our studies will identify candidate modifier alleles in patients with retinal degeneration, generate new models to study such phenomena and has the potential to inform the genetic basis of phenotypic variability, which in turn will contribute to the better diagnosis and long-term management of patients. PUBLIC HEALTH RELEVANCE: Retinal degeneration caused by dysfunction of ciliary proteins represents a frequent cause of both early onset and adult blindness, and the observed clinical variability among affected individuals poses a significant challenge in terms of prognosis and treatment. However, recent characterization of the ciliary proteome and the development of in vivo tools pose a unique opportunity to identify and model modifiers of both penetrance and expressivity in these disorders which in turn, has the potential of enhancing the predictive power of the genotype.